Nomination Form

FIRST SCHEDULE See Rules 8 (3) FORM OF NOMINATION Account No...................................................... I ….......................................................................................................... hereby nominate the person(s) mentioned below who is/are member(s)/non-member(s) of the family as defined in the rule 2 of the General Provident Fund (West Bengal Services) Rules to receive the amount that may stand to my credit in the fund as indicated by below, in the event of my death before that amount has become payable or having become payable has not been paid.

Name and full address of the nominee(s)

1

Relationship with the Age of the nominee(s) Share payable to each Contingencies on the subscriber nominee happening of which the nomination will become invalid.

2

3

4

Dated this................................day of............. ….....................19 Two witness to signature Name and address,

Names, address & relationship of the person if any, to whom the right of nominee shall pass in the event of his/her predecessing the subscriber

5

6

If the nominee is not a member of the family as provided in Rule 2 indicated the reasons

7

at..............................................

Signature Signature of the subscriber,

1. …..................................................................................................................

Name in Block letters.................................................................................................................

2. …..................................................................................................................

Designation.................................................................................................................................